In the last few years, new and improved treatments for vein diseases have become commonplace for many patients who previously had to suffer the pain and disfigurement of varicose veins and associated venous diagnoses. Vein diseases range from deep venous thrombosis (DVT) to varicose veins, venous rupture, and atherosclerosis (stricture due to plaque buildup inside of the veins). Therefore, it's important for medical coders to understand the procedures and correct CPT and ICD-9 coding related to varicose veins and similar diagnoses, especially venous ligation, stab phlebectomy, endovenous ablation, vein sclerosing, and miscellaneous vein procedures (e.g., venous ultrasound). Vein basics Veins carry de-oxygenated blood to the heart, while arteries carry re-oxygenated blood from the heart. There are superficial and subcutaneous veins; deep veins communicate between both sets. Veins do not accompany an artery. Veins also differ from arteries in that they:
- • handle a larger capacity of blood volume back to the heart
- • exist in greater numbers within the body
- • have thinner walls made up of three layers
- • have valves to prevent backflow or backward circulation
It is when the valves inside these veins stop working correctly that the blood within them backflows and causes the vein to enlarge and pool with stagnant blood. This is called a varicose vein. It is this reflux that causes the enlargement of the vein, often accompanied by pain. In addition to the pain, the enlargement can cause venous stasis ulcers and venous thrombosis. A venous stasis ulcer is an open wound, resulting from the pooling of non-oxygenated blood, which causes the skin/tissue to become thin and break open. Venous thrombosis is the pooling of nonoxygenated blood (and sometimes clotted blood) within the vein. Sometimes these clotted thromboli travel back toward the heart or lungs. There are many different causes of varicose veins. The most common factor is damaged/defective valves within the vein. Other factors contributing to the cause and severity of the condition include pregnancy, obesity, prolonged standing, prior leg surgery, and trauma to the leg, infection. Likewise, there are many different types of treatment for varicose veins, including:
• conservative (non-surgical) therapy
• light-based treatments
• endovenous procedures
Each of these therapies (and some others) is outlined below along with the accompanying CPT/ICD-9 codes. This is only a brief list. Consult your CPT and ICD-9 references to confirm your code choices. If you come across terminology that you are not familiar with, consult your medical dictionary to clarify the meaning before you code.
Conservative (non-surgical) therapy
Graduated compression hosiery, also known as "ted hose," is one conservative treatment for varicose veins. With graduated compression hosiery, the compression is tightest around the foot, ankle, and lower leg, and decreases in pressure as the stocking goes up around the calf and thigh. The most commonly prescribed form of graduated compression hosiery is the knee-high version. However, if the varicosity is above the knee, there are thigh-high, chap style, and body stocking versions (much like panty-hose). These stockings help prevent pooling of the blood in the lower extremity and promote normal blood flow back up the leg. Compression hosiery is available in many different compressions. The physician will prescribe the best compression for the patient. Although some compression hosiery is available at local drug stores, some must be ordered from your physician or durable medical equipment supplier. The HCPCS Manual describes the compression types and styles in detail. HCPCS codes change very often, so consult it prior to deciding upon a code. In addition to compression hosiery, other conservative options include the following:
• Elevating the patient's leg(s) above his or her heart when sitting or relaxing
• Walking (this stimulates the blood flow to/from the heart)
• Avoiding alcohol (it causes veins to dilate)
• Avoiding the crossing of legs/ankles when sitting
• Taking an hourly walk/stretch when sitting or driving for long periods of time (this allows the muscles to pump blood back out of the deeper vein system)
• Losing weight, or maintaining the current weight, if the patient is overweight (avoid yo-yo dieting)
Lasers and intense-pulsed light treatment (IPLT) are other forms of therapy for reducing redness and spider veins that are in the top layers of the skin. In both cases, the laser or intense light focuses through the skin on the spider vein, causing the blood in the vein to absorb the energy and collapse the vein closed. Superficial spider veins and redness on the outer layers of the skin do not normally cause any pain; most insurance carriers consider laser or IPLT treatments for these conditions to be cosmetic procedures. CPT does not have many codes for the light-based treatments, so you may have to bill with an unlisted code and denote the services on your claim form, backed up by physician documentation.
CPT codes: 17000-17108, 96567, +96570, +96571 96900, 96920-96922, 96999
Duplex ultrasound/doppler exam of the extremities (legs) Duplex or doppler evaluations of the veins in the arms and legs checks for the competency of the valves within the veins, looking for backflow or reflux blood flow within the vein. These scans use a combination of real-time ultrasound and doppler
CPT codes: 93965, 93970, 93971, 76937, 76942, 76000, 76001 76881, 76882
Intravascular ultrasound may be used during diagnostic evaluation of a noncoronary artery or vein. It may also be used to assess the patency and integrity of the vessel. A needle enters through the skin and goes into a blood vessel, allowing a guide wire to thread through the needle into the blood vessel. After removing the needle, the physician places an intravascular ultrasound catheter over the guide wire. This catheter can obtain images from inside the vessel that the physician uses to assess the area and extent of the disease prior to therapy. This can also help determine the adequacy of current therapy. The physician then removes the catheter and guide wire. CPT codes: +37250, +37251, 76937, 76942, 76000, 76001 Sclerotherapy Sclerotherapy is a procedure in which the physician injects a solution (sclerosant) percutaneously through the skin to the vein. This solution causes the vein to seal off, or sclerose/harden, stopping the blood flow through the vein. In some cases a physician will use ultrasound guidance in locating the vein. This is referred to as echoscherotherapy.
CPT codes: 36468, 36469, 36470, 36471, 76937, 76942, 76000-76003
Endovenous procedures are less risky than traditional surgical methods of varicose vein treatment. Endovenous therapy uses either a laser or radiofrequency to seal off the vein by use of a catheter. The catheter enters the vein and the heat from the laser or radiofrequency causes the vein to collapse, sealing off the blood flow. This procedure can occur in an outpatient or office-type setting, allowing the patient to recover quickly and resume normal activities. CPT codes: 36475, +36476, 36478, +36479
Surgical treatment options
The traditional surgical-based procedures for varicose veins are the following:
• Surgical ligation. The physician makes an incision close to the vein and ties off of the problematic varicose vein, stopping all blood flow through the vein.
• Surgical vein stripping. The physician makes an incision near the vein and uses a wire to pull out the problematic vein, then ties off or surgically closes the vein.
• Phlebectomy, or stab phlebectomy. The physician numbs the area surrounding the veins or vein cluster, incises the area, and uses a small hook to grasp and remove the vein or vein clusters.
These are commonly outpatient procedures, although some vein stripping and ligation procedures require an overnight stay in the hospital. Also, these procedures carry more risk than endovenous procedures. The severity of the varicosity determines whether the patient requires surgery or could be a candidate for phlebectomy or an endovenous procedure.
CPT codes: 37700, 37718, 37722, 37735, 37760, 37780, 37785 (ligations/stripping) 37765, 37766 (stab phlebectomy)
Diagnosis Codes for Vein procedures
The ICD-9 codes listed below are most commonly used for the venous procedures outlined above. However, this is not an all-inclusive list, and you will want to look at all 5th digits that may be needed. In addtion, you may want to look at or include other diagnoses with your coding.
• 440.20: Atherosclerosis of native arteries of the extremities, unspecified
• 451.0-451.2: Phlebitis and thrombophlebitis
• 453-453.9: Other venous embolism and thrombosis
• 454.0-454.9: Varicose veins
• 459.0-459.9: Other disorders of circulatory system (e.g., hemorrhage, ruptured blood vessel)
• 671.2-671.9: Venous complications in pregnancy
In closing - if you have questions, please don't hesitate to contact me. Happy Coding!